Untreated Mental Illness Is Global

A sizeable number of people around the world suffer from mental illness, and many of the most serious cases aren't being treated, a new study finds.

This treatment inequality could be rectified by a "reallocation of treatment resources," said the authors of the international survey published in the June 2 issue of the Journal of the American Medical Association. This week's journal is devoted to global health issues.

"The most surprising thing to me was how impairing we found the mental disorders to be in terms of days of role functioning, and how consistently that was true across the world," said study author Ronald C. Kessler, a professor of health-care policy at Harvard Medical School.

"I was amazed at how many other countries' people said 30 or 60 days a year they were totally unable to function. There really are just no other illnesses that have effects like this. It's not like a broken arm. The costs to society are just staggering."

Kessler, along with researchers from the World Health Organization (WHO) and the WHO World Mental Health Survey Consortium, culled data from 60,643 personal interviews in 14 countries. The countries were: Colombia, Mexico, the United States, Belgium, France, Germany, Italy, the Netherlands, Spain, Ukraine, Lebanon, Nigeria, Japan and separate surveys in Beijing and Shanghai, China.

Shanghai had the lowest prevalence of any mental disorder in the prior year (4.3 percent of the population), while the United States seemed to have the highest, with 26.4 percent.

Between 30 percent (Colombia) and 80.9 percent (Nigeria) of cases were classified as mild. Anxiety disorders were the most common in all areas except the Ukraine. Participants who reported serious disorders said there had been at least 30 days in the past year during which they couldn't function.

Some 36 percent to 50 percent of serious cases in developed countries and 76 percent to 85 percent in less-developed countries received no treatment at all in the year before the interview. Treatment for mild cases far exceeded that for serious cases.

"Even when resources are there, you find that there are poor people who are schizophrenic who are not getting treatment at all, and middle-class, middle-age women in suburbia who are seeing a psychiatrist three times a week," Kessler said. "There's a misallocation of resources and sometimes more so in poor countries because a lot of these countries don't have an enormous middle class. The 10 percent of the population that can afford it get all kinds of stuff and 90 percent can't. It's just sort of wacky."

Part of the problem is the "invisible" nature of these disorders, according to the study researchers.

"It's not entirely clear when these things are illnesses and when it gets to the point when it's big enough to be an illness, so there's a lot more discretion than in a broken-arm case," Kessler pointed out. "And when you have discretion in the allocation of resources, it goes in the direction of ability to pay."

Dr. Charles Goodstein, a clinical professor of psychiatry at New York University, cautions against overinterpretation of the findings. "When you survey 60,000 people, you're getting a sort of surface view of matters," he said. "Sometimes the ability to really diagnose and understand the severity of a problem only comes back when you have an opportunity to see a patient over time."

The authors agree this particular study only set out to get a handle on the extent and character of the problem.

"It's basically counting heads, but it's amazing when you do this head-counting stuff, you can get in there and find interesting things that have implications," Kessler said. "Already we can see from this data, things that need to be done and we're doing other surveys to help pinpoint how interventions should be done."

For instance, one striking characteristic of mental illness is that it tends to start very early in life, typically at the age of 16, Kessler said. The time to begin intervening is during the school years. This presents a unique window of opportunity, especially in less-developed countries, he said.

"The first thing that happens in all these countries even before sanitation is schools, so there's this one time in the life course where you know exactly where they're going to be, 9 to 3. There's a person standing up in front of the room who knows all these people," Kessler said.